NR226 EXAM 2 LATEST GUIDE
WITH ALL CORRECT ANSWERS
A new graduate nurse is providing a telephone report to a patient's health
care provider and accepting telephone orders from the provider. Which of the
following actions requires the new nurse's preceptor to intervene? The new
nurse:
A. Uses SBAR (Situation-Background-Assessment-Recommendation) as a
format when providing the report.
B. Gives a newly ordered medication before entering the order in the
patient's medical record.
C. Reads the orders back to the health care provider after receiving them and
verifies their accuracy.
D. Asks the preceptor to listen in on the phone conversation.
B. Gives a newly ordered medication before entering the order in the
patient's medical record
-Nurses enter orders into the computer or write them on the order sheet as
they are being given to allow the read-back process to occur.
As you enter the patient's room, you notice that he is anxious to say
something. He quickly states, "I don't know what's going on; I can't get an
explanation from my doctor about my test results. I want something done
about this." Which of the following is the most appropriate documentation of
the patient's emotional status?
A. The patient has a defiant attitude and is demanding his test results.
B. The patient appears to be upset with his nurse because he wants his test
results immediately.
C. The patient is demanding and complains frequently about his doctor.
D. The patient stated that he felt frustrated by the lack of information he
received regarding his tests.
,D. The patient stated that he felt frustrated by the lack of information he
received regarding his tests
-This is a nonjudgmental statement regarding the nurse's observations about
the patient. Documenting that the patient had a defiant attitude or was
demanding and frequently complaining is judgmental, and information in the
medical record should be factual and nonjudgmental. Documenting that the
patient appears upset needs to be more specific regarding the reason for the
patient's concern.
Which of the following charting entries is most accurate?
A. Patient walked up and down hallway with assistance, tolerated well.
B. Patient up, out of bed, walked down hallway and back to room, tolerated
well.
C. Patient up, walked 50 feet and back down hallway with assistance from
nurse. Spouse also accompanied patient during the walk.
D. Patient walked 50 feet and back down hallway with assistance from nurse;
HR 88 and regular before exercise, 94 and regular following exercise.
D. Patient walked 50 feet and back down hallway with assistance from nurse;
HR 88 and regular before exercise, 94 and regular following exercise
While reviewing the pulmonary section of a patient's electronic chart, the
physician notices blank spaces since the initial assessment the previous day
when the nurse documented that the lung assessment was within normal
limits. There also are no progress notes about the patient's respiratory status
in the nurse's notes. The most likely reason for this is because:
A. The nurses forgot to document on the pulmonary system.
B. The nurses were charting by exception.
C. The computer is not working correctly.
D. The physician does not have authorization to view the nursing
assessment.
,B. The nurses were charting by exception
-Given that the initial assessment indicated that the pulmonary system was
within normal limits, the facility is most likely documenting by exception.
There is no need for further documentation unless the pulmonary
assessment changes and is no longer within normal limits.
While assessing a patient, the nurse observes that the patient's intravenous
(IV) line is not infusing at the ordered rate. The nurse assesses the patient
for pain at the IV site, checks the flow regulator on the tubing, looks to see if
the patient is lying on the tubing, checks the point of connection between
the tubing and the IV catheter, and then checks the condition of the site
where the intravenous catheter enters the patient's skin. After the nurse
readjusts the flow rate, the infusion begins at the correct rate. This is an
example of:
A. Inference.
B. Diagnostic reasoning.
C. Competency.
D. Problem solving.
D. Problem solving
-This is an example of problem solving. The nurse collects information and
tries options until she is able to find a solution to the slowed infusion rate.
The focus is on solving the problem with the patient's IV and not on solving
the patient's health problem; thus this is not the diagnostic reasoning
process.
The nurse sits down to talk with a patient who lost her sister 2 weeks ago.
The patient reports she is unable to sleep, feels very fatigued during the day,
and is having trouble at work. The nurse asks her to clarify the type of
trouble. The patient explains she can't concentrate or even solve simple
, problems. The nurse records the results of the assessment, describing the
patient as having ineffective coping. This is an example of:
A. Diagnostic reasoning.
B. Competency.
C. Inference.
D. Problem solving.
A. Diagnostic reasoning
-In this example the nurse collects information about the patient, sees
patterns in the data collected, and makes a nursing diagnosis. This is an
example of the diagnostic process.
A nurse has worked on an oncology unit for 3 years. One patient has become
visibly weaker and states, "I feel funny." The nurse knows how patients often
have behavior changes before developing sepsis when they have cancer. The
nurse asks the patient questions to assess thinking skills and notices the
patient shivering. The nurse goes to the phone, calls the physician, and
begins the conversation by saying, "I believe that your patient is developing
sepsis. I want to report symptoms I'm seeing." What examples of critical
thinking concepts does the nurse show? (Select all that apply.)
A. Experience
B. Ethical
C. Analyticity
D. Self-confidence
E. Risk taking
C & D.
-Among critical thinking concepts, the nurse shows analyticity (analyzing
information, gathering additional findings, and sensing a problem), and self-
confidence (calling the physician, which shows trust in his own reasoning).
The nurse's experience would have influenced the familiarity of patient
symptoms, but in this text experience is considered a component of the
WITH ALL CORRECT ANSWERS
A new graduate nurse is providing a telephone report to a patient's health
care provider and accepting telephone orders from the provider. Which of the
following actions requires the new nurse's preceptor to intervene? The new
nurse:
A. Uses SBAR (Situation-Background-Assessment-Recommendation) as a
format when providing the report.
B. Gives a newly ordered medication before entering the order in the
patient's medical record.
C. Reads the orders back to the health care provider after receiving them and
verifies their accuracy.
D. Asks the preceptor to listen in on the phone conversation.
B. Gives a newly ordered medication before entering the order in the
patient's medical record
-Nurses enter orders into the computer or write them on the order sheet as
they are being given to allow the read-back process to occur.
As you enter the patient's room, you notice that he is anxious to say
something. He quickly states, "I don't know what's going on; I can't get an
explanation from my doctor about my test results. I want something done
about this." Which of the following is the most appropriate documentation of
the patient's emotional status?
A. The patient has a defiant attitude and is demanding his test results.
B. The patient appears to be upset with his nurse because he wants his test
results immediately.
C. The patient is demanding and complains frequently about his doctor.
D. The patient stated that he felt frustrated by the lack of information he
received regarding his tests.
,D. The patient stated that he felt frustrated by the lack of information he
received regarding his tests
-This is a nonjudgmental statement regarding the nurse's observations about
the patient. Documenting that the patient had a defiant attitude or was
demanding and frequently complaining is judgmental, and information in the
medical record should be factual and nonjudgmental. Documenting that the
patient appears upset needs to be more specific regarding the reason for the
patient's concern.
Which of the following charting entries is most accurate?
A. Patient walked up and down hallway with assistance, tolerated well.
B. Patient up, out of bed, walked down hallway and back to room, tolerated
well.
C. Patient up, walked 50 feet and back down hallway with assistance from
nurse. Spouse also accompanied patient during the walk.
D. Patient walked 50 feet and back down hallway with assistance from nurse;
HR 88 and regular before exercise, 94 and regular following exercise.
D. Patient walked 50 feet and back down hallway with assistance from nurse;
HR 88 and regular before exercise, 94 and regular following exercise
While reviewing the pulmonary section of a patient's electronic chart, the
physician notices blank spaces since the initial assessment the previous day
when the nurse documented that the lung assessment was within normal
limits. There also are no progress notes about the patient's respiratory status
in the nurse's notes. The most likely reason for this is because:
A. The nurses forgot to document on the pulmonary system.
B. The nurses were charting by exception.
C. The computer is not working correctly.
D. The physician does not have authorization to view the nursing
assessment.
,B. The nurses were charting by exception
-Given that the initial assessment indicated that the pulmonary system was
within normal limits, the facility is most likely documenting by exception.
There is no need for further documentation unless the pulmonary
assessment changes and is no longer within normal limits.
While assessing a patient, the nurse observes that the patient's intravenous
(IV) line is not infusing at the ordered rate. The nurse assesses the patient
for pain at the IV site, checks the flow regulator on the tubing, looks to see if
the patient is lying on the tubing, checks the point of connection between
the tubing and the IV catheter, and then checks the condition of the site
where the intravenous catheter enters the patient's skin. After the nurse
readjusts the flow rate, the infusion begins at the correct rate. This is an
example of:
A. Inference.
B. Diagnostic reasoning.
C. Competency.
D. Problem solving.
D. Problem solving
-This is an example of problem solving. The nurse collects information and
tries options until she is able to find a solution to the slowed infusion rate.
The focus is on solving the problem with the patient's IV and not on solving
the patient's health problem; thus this is not the diagnostic reasoning
process.
The nurse sits down to talk with a patient who lost her sister 2 weeks ago.
The patient reports she is unable to sleep, feels very fatigued during the day,
and is having trouble at work. The nurse asks her to clarify the type of
trouble. The patient explains she can't concentrate or even solve simple
, problems. The nurse records the results of the assessment, describing the
patient as having ineffective coping. This is an example of:
A. Diagnostic reasoning.
B. Competency.
C. Inference.
D. Problem solving.
A. Diagnostic reasoning
-In this example the nurse collects information about the patient, sees
patterns in the data collected, and makes a nursing diagnosis. This is an
example of the diagnostic process.
A nurse has worked on an oncology unit for 3 years. One patient has become
visibly weaker and states, "I feel funny." The nurse knows how patients often
have behavior changes before developing sepsis when they have cancer. The
nurse asks the patient questions to assess thinking skills and notices the
patient shivering. The nurse goes to the phone, calls the physician, and
begins the conversation by saying, "I believe that your patient is developing
sepsis. I want to report symptoms I'm seeing." What examples of critical
thinking concepts does the nurse show? (Select all that apply.)
A. Experience
B. Ethical
C. Analyticity
D. Self-confidence
E. Risk taking
C & D.
-Among critical thinking concepts, the nurse shows analyticity (analyzing
information, gathering additional findings, and sensing a problem), and self-
confidence (calling the physician, which shows trust in his own reasoning).
The nurse's experience would have influenced the familiarity of patient
symptoms, but in this text experience is considered a component of the
